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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 05/13/2024
Date Signed: 05/13/2024 01:18:23 PM


Document Has Been Signed on 05/13/2024 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:AEGIS ASSISTED LIVING AT SHADOWRIDGEFACILITY NUMBER:
374602653
ADMINISTRATOR:LANCE SHENKFACILITY TYPE:
740
ADDRESS:1440 SOUTH MELROSE DRIVETELEPHONE:
(760) 806-3600
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:95CENSUS: 65DATE:
05/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Health Services Director Claire MolinaTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Health Services Director (HSD) Claire Molina. General Manager Charles Bloom arrived during the visit. During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents.

The purpose of today's visit was to conduct follow up regarding a self-reported incident. On 4/19/2024, the Department received an incident report from the facility describing an incident that occurred on 4/15/2024, where staff discovered that Resident 2's (R2) medication patch was not being administered as ordered. [HSD was provided with an LIC811 Confidential Names List to identify individuals]. Interviews with HSD revealed that the facility receives orders from the pharmacy and facility nurses review and approve the medication order prior to administering medications. Interviews with HSD and review of R2's electronic medication administration record (E-MAR) revealed that the medication patch was ordered to be given every 3 days or every 72 hours. R2's medication patch had a scheduling detail that was input into the E-MAR system stating that the medication patch was to be replaced every 4 days. Interviews with HSD stated that R2's pharmacy would occasionally provide scheduling details for medications, and HSD was provided with conflicting information from the pharmacy regarding if the pharmacy provided scheduling information for R2's patch. R2's E-MAR revealed that R2 had been receiving the medication patch every 4 days from October 2023 to 4/15/2024, which is not as the medication was ordered from R2's physician. Interviews with HSD revealed that R2 had not been experiencing any adverse effects due to the medication being administered not as ordered.

The following deficiency for medication administration is being cited and noted on the attached LIC809-D page. An exit interview was conducted with General Manager Charles Bloom and HSD Claire Molina, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2024 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: AEGIS ASSISTED LIVING AT SHADOWRIDGE
FACILITY NUMBER: 374602653

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
87645(c)(2)

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87465 Incident Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by:
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HSD and General Manager conducted an in-service training for staff on proper medication administration and verification on 4/16/2024 after discovering the medication error.
DEFICIENCY CLEARED.
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Based on interview and record review, the licensee did not ensure that R2's medication patch was administered as ordered by the physician. This poses a potential health risk to 65 of 65 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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